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Wednesday, November 23, 2011

You do not have to intubate if you have a good airway

Other than certain ethical issues, the things that irritates this RT more than anything are when certain medical workers become rapt on the idea they have to intubate right away during a respiratory or cardiopulmonary arrest. The patient turns blue and they think intubate. The neonate needs CPR and they think intubate.

An intubated patient is easier to ventilate that's no doubt, yet more often than not the process wastes valuable time better spent giving breaths, giving chest compressions, and giving medicines. In most instances, I think intubation can wait until you have the situation under control.

In fact, we'll just jump to the case here and come out with RT Cave Rule #52:

RT Cave Rule #52: So long as you have a good airway and ventilations are effective, intubation can wait until the patient is stabilized.

Under stress of a code intubation is often the first thing to come to mind. It shouldn't be. The first thing to come to your mind should be "are we ventilating?" If yes, leave well enough alone and move on to the next question: "are we circulating blood?" If the answer to both these are yes, then you can intubate.

Now obviously there are exceptions to this rule, such as obstructed airway. Yet this would still fall under rule #52 which states, "so long as you have a good airway." If you don't have a good airway, then you can rush to intubate. In that case, you have to intubate.

Some people might contend another exception is overdose and high risk for aspiration. Yet I would never recommend intubating such a patient. Why you ask? Because sticking a hard, metal object through someone's gag reflex is the perfect way to get someone to vomit.

But you don't have to intubate a neonate you just started doing chest compressions on. I sat and watched a doctor doing this, and also watched as the pulse oximeter went from 90 to 80 to 70 to 60. I verbalized these falling heart rates and the doctor said, "Don't worry about it."

Sorry, but I was right and that doctor was wrong. He spent way too much time trying to intubate, and his attempt, even while he had noble intentions, was inappropriate.